Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence?

BACKGROUND: While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias. METHODS: The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias. RESULTS: The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083). CONCLUSIONS: Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.

The pathological conditions and surgical outcomes depending on the degree of hernia in the intra-thoracic stomach.

BACKGROUND: In recent years, the number of patients requiring surgery for intra-thoracic stomach (ITS) has been increasing due to the effects of obesity and gibbus due to aging. The aim of this study is to assess the effects of the degree of hernia on the pathological conditions and surgical outcomes in ITS patients. METHODS: ITS was defined as cases in which over 50% of the stomach had deviated into the mediastinum by esophagogastric fluoroscopy and/or computed tomography, with 65 patients who underwent laparoscopic surgery as the initial surgery included. We compared the pathological conditions and surgical outcomes by dividing the subjects into 3 groups: Group A: 50%- < 75%; Group B: 75%- < 100%; and Group C: 100% (upside-down stomach), depending on the degree of deviation into the mediastinum of the stomach. RESULTS: The breakdown of patients was 33 in Group A, 21 in Group B, and 11 in Group C. Regarding the preoperative pathological conditions, Group C had a high body mass index (BMI) and a low score for factor V according to upper gastrointestinal endoscopy (p = 0.0109, p = 0.0062, respectively). While the surgical results indicated that the operation time was extended depending on the degree of hernia (p = 0.0051), there was no marked difference in other surgical outcomes or the postoperative course among the three groups, with a high degree of satisfaction. CONCLUSIONS: In the case of ITS, although the operation time was extended depending on the degree of the hernia, the surgical outcomes were the same, and overall good results were obtained.

Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia?

BACKGROUND: Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. METHODS: We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. RESULTS: Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. CONCLUSION: The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia.

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

Correlation between our symptom-based scoring system and the Eckardt score for assessing patients with esophageal achalasia.

PURPOSE: The Eckardt score (ES) is a famous scoring system used for assessing achalasia patients. We studied the correlation between our scoring system and the ES and examined the relationship between each score and the pathophysiology of achalasia. METHODS: The subjects were 143 patients with diagnosed achalasia. We assessed the frequency and degree of dysphagia, regurgitation (vomiting), and chest pain on a 5-point scale from 0 to 4, with the product of the frequency and degree score defined as each symptom score (0-16). The sum of the three symptom scores was the Total Symptom Score (TSS). We then studied the correlation between the TSS and the ES, including whether these scores reflected the pathophysiology. RESULTS: The median scores were 20 for TSS and 6 for the ES, indicating a high correlation between the two scores (r = 0.7280, p < 0.0001). A relationship was found between the morphologic type and both scores (TSS: p = 0.002, ES: p = 0.0036). On creating a receiver operating characteristic (ROC) curve for the Straight type and each score, the AUC was 0.6740 for TSS and 0.6628 for ES. CONCLUSIONS: A high positive correlation was found between the TSS and the ES. Both scoring systems reflected the morphologic type well, demonstrating that the TSS was a scoring system comparable to the ES.

Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience.

PURPOSE: To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. METHODS: We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. RESULTS: Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. CONCLUSIONS: Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.

Relationship between esophageal achalasia subtypes and esophageal clearance.

BACKGROUND: The diagnosis and pathological evaluation of esophageal achalasia have been improved dramatically by the development of high-resolution manometry. It is currently known to be divided into three subtypes. However, the differences between subtypes in terms of esophageal clearance remain unclear. AIMS: To compare the pathology of subtypes in patients with esophageal achalasia from the perspective of esophageal clearance. METHODS: We classified the patients diagnosed with esophageal achalasia into three subtypes based on the high-resolution manometry findings and compared the patient background, esophagography findings, esophageal manometry findings, timed barium esophagogram (TBE) findings, and their symptoms. We also calculated the esophageal clearance rate from TBE to investigate the relationship with the subtypes. RESULTS: There were 71 cases of Type I, 140 cases of Type II, and 10 cases of Type III. No differences by subtype were found in patient background or symptoms. Regarding the esophageal manometry findings, the integrated relaxation pressure was high in Type II (p = 0.0006). The esophagography revealed a mild degree of esophageal flexion in Type III (p = 0.0022) and a high degree of esophageal dilation in Type I and II (p = 0.0227). The esophageal clearance rate in descending order was: Type III, II, and I (height: p = 0.0302, width: p = 0.0008). CONCLUSIONS: The subtypes by high-resolution manometry diagnosis had an association with the esophagography findings and best reflected the esophageal clearance, with no correlation to the patient backgrounds and symptoms.

Over ten-year outcomes of laparoscopic Heller-myotomy with Dor-fundoplication with achalasia: single-center experience with annual endoscopic surveillance.

BACKGROUND: Laparoscopic Heller-myotomy with Dor-fundoplication (LHD) is the standard surgical treatment for achalasia; however, surgical outcomes over a period greater than 10 years have not been well-explored. The objective of this study was to evaluate the long-term outcomes of LHD for achalasia based on a single-center experience. METHODS: Patients who underwent LHD between 1994 and 2019 were included. Of these, we excluded patients who had undergone foregut surgery or whose follow-up data were unavailable. Esophagogastroduodenoscopy (EGD) findings and postoperative persistent and/or recurrent symptoms had been assessed annually. Disease-free rates were calculated using Kaplan-Meier analysis. RESULTS: A total of 530 patients (mean age 45.0 years with 267 men) were included. The median follow-up period was 50.5 months. More than 10 years' data were available in 78 patients (14.7%). The cumulative rates of freedom from dysphagia, vomiting, chest pain, and Eckardt score > 3 at 10 years after LHD were 80.1%, 97.5%, 96.3%, and 73.5%, respectively. Probability of esophagitis during 10 years after surgery was 34.4% of patients based on Kaplan-Meier estimation. Approximately 3/4th of patients who had post-LHD esophagitis showed mild esophagitis of Los Angeles classification grade A. Fifteen patients (2.8%) were required a revision of primary LHD. Six patients (1.2%) developed esophageal cancer with an incidence was as high as 219.8/100,000 person-year. All patients with esophageal cancer were found to have early stage tumors that were successfully resected. CONCLUSIONS: Symptomatic relief post-LHD lasted for over 10 years. The incidence rate of esophageal cancer was high. Regular EGD surveillance seems to be helpful for early detection of esophageal cancer early.

Effects of the preoperative IRP values on the pathophysiology of patients with esophageal achalasia and on the treatment outcome of laparoscopic Heller-Dor surgery.

PURPOSE: One diagnostic criterion of esophageal achalasia is that the integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) is at least 15 mmHg. Moreover, while the standard surgical treatment for esophageal achalasia is laparoscopic Heller-Dor surgery (LHD), there have been insufficient investigations concerning the surgical outcomes from the perspective of the preoperative IRP value. METHODS: We split 121 cases in which LHD was performed as an initial treatment on patients with esophageal achalasia, into two categories according to the IRP median value, and performed a comparative investigation of the surgical outcomes with regard to the preoperative pathophysiology and symptoms. RESULTS: The IRP median value was 29.6 mmHg. The high IRP group consisted of younger individuals and low BMI (p = 0.004 and p = 0.0273, respectively), and the percentage of Chicago classification Type II and III was high (p = 0.029) and the regurgitation score in the preoperative symptoms was high (p = 0.0043). However, no differences in the surgical outcomes were confirmed. CONCLUSION: In patients with esophageal achalasia, the degree of the preoperative IRP value affects the age, BMI, preoperative LESP, and preoperative regurgitation symptoms. However, there were no effects on the surgical outcomes, with the surgical outcomes being satisfactory, regardless of the IRP value.

The patient characteristics of esophageal carcinoma following laparoscopic myotomy for esophageal achalasia.

BACKGROUND: It is common knowledge that esophageal achalasia patients have a high risk of developing esophageal carcinoma. The present study assessed the characteristics of esophageal carcinoma patients following laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia. METHOD: Among 622 cases which were esophageal achalasia patients and underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not esophageal carcinoma occurred following surgery. RESULTS: Six cases (0.96%) of postoperative esophageal carcinoma were confirmed. The characteristics of the cases in which esophageal carcinoma occurred were older age, longer disease duration (p = 0.0362 and 0.0028, respectively), decreased sphincter pressure of the lower esophagus, a high rate of sigmoid esophagus, and a long esophagus lateral diameter (p = 0.0214, 0.001, and 0.0416, respectively). Moreover, no differences in surgical outcomes were confirmed and there were no differences in symptoms from before and following surgery. CONCLUSION: The characteristics of esophageal carcinoma patients with achalasia following laparoscopic myotomy were an older age, longer disease duration, and greater progression of disease pathophysiology.

The evaluation of the dilation-degree classification of esophageal achalasia patients from the viewpoint of esophageal clearance.

PURPOSE: To examine whether or not we could propose a more appropriate dilation-degree classification suitable for the pathological condition of patients with esophageal achalasia. METHODS: In accordance with the current dilation-degree classification, the maximum dilated diameter was measured based on the esophageal barium swallow. The relationship between the pathophysiology and dilation-degree classification was examined. Furthermore, the current dilatation-degree classification from the viewpoint of esophageal clearance was evaluated to examine whether or not a more appropriate dilatation-degree classification could be proposed. RESULTS: Because the clearance ratio tended to decrease at a maximum expansion diameter of 80 mm, when the maximum dilated diameter was divided into units of 10 mm, they were classified into two groups, with 80 mm as the boundary. As a result, the illness period was significantly prolonged (p = 0.0045) and the frequency of sigmoid type was high (p < 0.001) for lengths of ≥ 80 mm. With regard to the esophageal clearance rate, the clearance rate was significantly decreased in patients with a diameter of ≥ 80 mm at 5 min after taking barium (p = 0.0229). CONCLUSIONS: From the viewpoint of esophageal clearance, classification into 2 groups with a boundary of 80 mm may reflect the pathological condition.

Factors affecting the treatment outcomes of laparoscopic fundoplication for erosive reflux esophagitis: findings of esophageal pathological function tests.

PURPOSE: To identify the factors that affect laparoscopic fundoplication (LF) treatment efficacy in patients with erosive gastroesophageal reflux disease (e-GERD) esophagitis, based on the findings of multichannel intraluminal impedance pH (MII-pH) and high-resolution manometry (HRM). METHODS: The subjects were 102 patients with e-GERD diagnosed by endoscopy, who underwent LF as the initial surgery. To analyze the findings of MII-pH and HRM, the patients were divided into two groups: a cured group (CR), comprised of patients whose esophagitis was cured postoperatively; and a recurrence group (RE), comprised of patients who suffered recurrent esophagitis. RESULTS: There were 96 patients in the CR group and 6 in the RE group. MII-pH indicated that the acid reflux time, the longest reflux time, and the number of refluxes longer than 5 min, were significantly higher in the RE group than in the CR group (p = 0.0028, p = 0.0008, p = 0.012, respectively). The HRM indicated that only the distal contractile integral (DCI) was significantly lower in the RE group (p = 0.0109). CONCLUSION: The results of this study indicate that esophageal clearance may affect the treatment outcome of LF. Based on the findings of MII-pH, the longest reflux time and the number of refluxes longer than 5 min were important factors influencing the therapeutic effect, whereas based on the HRM, the DCI value was most important.

Is esophageal manometry essential for the diagnosis of achalasia? Identifying patients with achalasia by the esophageal clearance method.

BACKGROUND AND AIM: Achalasia is a disease characterized by inadequate relaxation of the lower esophageal sphincter (LES) and impaired peristalsis, for which esophageal motor function testing is essential in making a definitive diagnosis. However, the diffusion rate of esophageal pressure testing in Japan is low. We, therefore, examined whether achalasia could be identified by esophageal clearance testing with low-density barium (Timed Barium Esophagogram: TBE). MATERIALS AND METHODS: 126 cases (62 males, median age of 46 years), excluding those who had not undergone TBE during their initial laparoscopic Heller-Dor surgery, were chosen as the subjects from among those who were diagnosed with achalasia from November 2012 when HRM was introduced. The type of dilation, maximum esophageal transverse diameter, and esophageal clearance measurements by TBE were retrospectively examined. With respect to TBE, 200 mL of 45 weight% low-density barium was ingested as quickly as possible, after which the barium column heights (H0, H1, H2, and H5) were measured 1 min, 2 min, and 5 min following ingestion. RESULTS: The types of dilation indicated included: straight type (105 cases, 83%); sigmoid type (20 cases, 16%); and advanced sigmoid type (1 case, 1%). The maximum transverse diameter of the esophagus was 45 (34-54) mm, with Grade I (d < 30 mm) in 33 cases, Grade II (35 mm < d < 60 mm) in 75 cases, and Grade III (d < 60 mm) in 18 cases. The values for H0, H1, H2, and H5 were 162 (117-201) mm, 142 (98-199) mm, 130 (94-183) mm, and 119 (77-178) mm, respectively. 114 cases (90.5%) were not cleared after 5 min, while 12 cases (9.5%) were cleared by 5 min later (H1 = 0 + H2 = 0 + H5 = 0) and 7 cases (5.6%) by 2 min later (H1 = 0 + H2 = 0), with only 6 cases (4.8%) having complete clearance within 1 min (H1 = 0). Moreover, the degree of dilatation in patients with complete clearance within 1 min was three patients (2.4%) each for Grade I and Grade II, respectively. CONCLUSIONS: Approximately 2.4% of achalasia cases had mostly normal esophageal clearance and no esophageal dilation. Based on the state of esophageal clearance by TBE and the maximum transverse diameter of the esophagus, it seems by and large possible to identify achalasia cases.

Therapeutic effect of laparoscopic fundoplication for patients with GERD from the viewpoint of Lyon Consensus.

BACKGROUND AND OBJECTIVES: The Lyon Consensus was conducted in 2017, leading to a revision of the diagnostic criteria of GERD. Conclusive GERD was defined as cases in which the distal esophageal acid exposure time (AET) is greater than 6% and there exists either peptic esophagitis, constriction, or long-segment Barrett's mucosa with a Los Angeles classification of grade C or D. Borderline GERD is defined as cases in which AET is between 4 and 6% and there exists peptic esophagitis with a Los Angeles classification of either grade A or B. All other cases were defined as Inconclusive GERD. We conducted a retrospective investigation of the treatment results of laparoscopic fundoplication (LF) for GERD according to the Lyon Consensus and evaluated whether or not it is an effective treatment predictor. MATERIALS AND METHODS: From among the cases of primary LF conducted on patients with GERD-related illnesses at our university hospital from June 2008 to March 2020, the subjects included 215 individuals who underwent upper gastrointestinal endoscopy and 24 h multichannel intraluminal impedance pH (MII-pH) testing prior to surgery. We compared the pathophysiology of the Conclusive GERD Group (Group A), Borderline GERD Group (Group B), and Inconclusive GERD Group (Group C), and then investigated the treatment results of each group. We used AFP classification for pathophysiological evaluation. For the acid reflux evaluation, we conducted MII-pH measurements using Sleuth, manufactured by Sandhill. The postoperative evaluation period was set to 3 months following surgery. The data are expressed using median values, with a statistical significance defined as p < 0.05 using the Kruskal-Wallis, Mann-Whitney, Wilcoxon signed-rank, and Chi-squared tests. RESULTS: Group A: 92 cases (43%, male 69 cases, age 57), Group B: 48 cases (22%, male 20 cases, age 52), and Group C: 75 cases (35%, male 69 cases, age 57). Regarding the patient backgrounds, while there were no significant differences in terms of gender or disease duration, those in Group A were significantly older than the other two groups, and there was a significant difference in Body Mass Index (BMI) between Group A and Group C. The results of each factor were: A factor (1 vs.1 vs. 1, p < 0.001), F factor (2 vs. 0 vs. 0, p < 0.001), and P factor (2 vs. 1 vs. 0, p < 0.001), with AET of 10.0 vs. 2.9 vs. 0.6, p < 0.001, and the disease had progressed more in Group A. There were also no differences in terms of surgical methods, hemorrhage volume, and intraoperative/postoperative complications; however, the use of mesh was higher and surgery duration was longer in Group A. There were obvious improvements in the A, F, and P factors and AET of each group following surgery (other than F and P of Group C, p < 0.001). The rate of recurrence was 15% in Group A, 8% in Group B, and 6% in Group C. It tended to be higher in Group A, but this was not statistically significant. CONCLUSION: The classification of GERD pathophysiology based on the Lyon Consensus is satisfactory, with no significant differences in the rate of effect of LF. The Lyon Consensus is effective for ascertaining the severity and pathophysiology of GERD; however, we were unable to forecast the treatment results of LF.

Needlescopic versus conventional laparoscopic Heller-Dor procedure for achalasia: a propensity score-matched analysis.

PURPOSE: To compare the treatment results of needlescopic surgery with those of the conventional method for achalasia, using propensity score-matching. METHODS: Propensity score-matching was performed based on five factors: age, gender, body mass index, extended form, and maximum expansion diameter, to extract 28 cases each for a needlescopic group and a conventional group. RESULTS: There were no significant differences between the needlescopic group and the conventional group, in operative time (165 min vs. 170 min, p = 0.682), estimated blood loss (both ≒ 0 ml, p = 0.426), or post-operative hospital stay (4 vs. 4 days, p = 0.248). Although the follow-up period was significantly longer in the conventional group (6 vs. 105 months, respectively; p < 0.001), there was no difference in the post-operative symptom scores for difficulty in swallowing and chest pain or the degree of satisfaction (p = 0.563, p = 0.142, p = 0.342, respectively). Furthermore, there was no difference in the post-operative clearance rate, with both groups found to be favorable (p = 0.758, p = 0.790, p = 1.000, p = 1.000, respectively). CONCLUSIONS: The short-term results of needlescopic surgery for achalasia were good and equivalent to those of the conventional method.

Circumferential Heller myotomy can relieve chest pain in patients with achalasia: a prospective clinical trial.

BACKGROUND: Noncardiac chest pain often coexists with dysphagia in patients diagnosed with achalasia. The current standard treatment for achalasia, laparoscopic Heller myotomy with Dor fundoplication, has an insufficient effect on noncardiac chest pain. The aim of this study is to investigate the efficacy of circumferential Heller myotomy on esophageal chest pain in patients with achalasia. METHODS: Twenty patients diagnosed with achalasia who complained of noncardiac chest pain were recruited and underwent circumferential Heller myotomy. Using an institutional achalasia database, we randomly selected 60 patients who underwent standard laparoscopic Heller myotomy with Dor fundoplication, based on a 3-to-1 propensity score-matching analysis. We compared surgical outcomes between the circumferential Heller myotomy and the laparoscopic Heller myotomy with Dor fundoplication groups. RESULTS: Patients undergoing circumferential Heller myotomy had a higher rate of postoperative noncardiac chest pain relief than the laparoscopic Heller myotomy with Dor fundoplication group [95% (19/20) vs. 75% (45/60), p = 0.045]. No differences in dysphagia and vomiting were found between groups (p = 0.783 and p = 0.645, respectively). Patients in the circumferential Heller myotomy group had significantly better esophageal clearance. The prevalence of reflux endoscopic esophagitis was higher in the circumferential Heller myotomy group than in the control group [35.0% (7/20) vs. 10.0% (6/60), p = 0.015]. CONCLUSIONS: There is promising early evidence that circumferential Heller myotomy may be effective in the treatment of achalasia-related chest pain. Further research, including larger randomized studies with long-term follow-up, is warranted.

The evaluation of recumbent reflux by multichannel intraluminal impedance pH testing for patients with gastroesophageal reflux disease and sleep disturbance.

BACKGROUND AND AIM: The relationship between gastroesophageal reflux disease (GERD) and sleep disturbance has recently been pointed out and is garnering substantial attention. Although there are reports that point out the effectiveness of medical treatment for sleep disturbance associated with GERD, examinations of the pathological condition, including reflux during sleep, are inadequate. In the present study, we evaluated the recumbent reflux in patients with GERD and sleep disturbance using multichannel intraluminal impedance pH (MII-pH), and attempted to suppress recumbent reflux by surgical treatment to examine the pathophysiology of patients with GERD and sleep disturbance. MATERIALS AND METHODS: Of the 47 patients with GERD-related diseases in whom laparoscopic fundoplication was performed at The Jikei University Hospital from January 2016 to June 2017, 31 patients (average age: 55.9 ± 13.8 years, male in 25), excluding 9 with surgical indications only for esophageal hiatal hernia and 7 without postoperative evaluation, were the subjects of this study. All surgical procedures were performed by the Toupet method. We used the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep disturbance, setting 5.5 as the cut-off value, based on the report by Doi et al., with any conditions beyond this value deemed sleep disturbance. The evaluation of gastroesophageal reflux was carried based on the MII-pH using the Sleuth, manufactured by Sandhill Corporation, with an automatic analysis carried out by computer. Furthermore, recumbent abnormal reflux was defined as recumbent all reflux (times) > 7. All evaluations were performed preoperatively and at 3 months after the operation. The data were expressed in medians and interquartile ranges, with p < 0.05 defined as statistically significant by the Mann-Whitney, Wilcoxon, or Chi-squared test. RESULTS: Although sleep disturbance was found in 19 cases (61%), 8 (42%) of which were actually confirmed as nighttime abnormal reflux, of whom 5 cases (63%) showed significant improvement in their sleep disturbance following the operation, with a PSQI score of lower than 5.5. Among these 5 cases, postoperative recumbent abnormal reflux was also significantly reduced as compared with the preoperative condition (17 vs. 2 times/day, p = 0.042). Furthermore, sleep disturbance improved and recumbent abnormal reflux also decreased in two cases, with sleep disturbance improved by controlling the nighttime reflux via surgery in a total of 7 cases (87.5%). Although the PSQI score was as high as 14 points before and after the operation in one case, the rate of recumbent abnormal reflux was remarkably reduced, with sleep disturbance and recumbent reflux considered irrelevant. Furthermore, regarding the frequency of recumbent acid/non-acid reflux, while non-acid reflux was significantly more frequent in the patients with recumbent reflux complications (9 vs. 1 time/day, p < 0.001), there was no marked difference in the frequency of acid reflux. CONCLUSIONS: Among cases with GERD and sleep disturbance, approximately one-third of them showed findings suggestive of the involvement of recumbent reflux in sleep disturbance, with reflux characterized by non-acid reflux.

Therapeutic efficacy of laparoscopic Heller-Dor surgery for chest pain in patients with achalasia: a single institutional experience.

BACKGROUND: Chest pain reduces the quality of life of patients with achalasia. Although laparoscopic Heller-Dor surgery (LHD) is a standard surgical treatment for achalasia, its therapeutic efficacy for chest pain is not clear. The present study evaluated the therapeutic efficacy of LHD for chest pain and tried to identify factors associated with the relief of chest pain. METHODS: The study included 244 patients with preoperative chest pain who underwent LHD as the first surgical intervention. The questionnaire-based symptom frequency score was multiplied by the severity score, and the calculated metric was defined as the symptom score. The study population was stratified, by the change in the chest pain symptom score, into Complete Remission (CR), Partial Remission (PR), and No Remission (NR) groups, which were compared for patient background and surgical outcome. Multivariate analysis was also performed to determine factors associated with the relief of chest pain. RESULTS: As for preoperative clinicopathological conditions, the CR subgroup was older (p = 0.0169) with fewer previous balloon dilatations (p = 0.009). Although no difference was detected in the surgical outcome, the NR group had higher postoperative symptom scores for both difficulty in swallowing and vomiting and a lower score for patient satisfaction with surgery (p = 0.0141). Multivariate analysis detected two factors associated with CR: disease duration over 60 months and less than two previous balloon dilatations. CONCLUSIONS: LHD improved chest pain symptoms in 90% of patients with achalasia. The patients who achieved relief of chest pain were characterized by disease duration over 60 months and less than two previous balloon dilatations.

Effect of Low-Dose Aspirin on Chronic Acid Reflux Esophagitis in Rats.

BACKGROUND: Clinical role of low-dose aspirin (LDA) in pathogenesis of gastroesophageal reflux disease is by far controversial. This can be attributed to the paucity of basic research detailing the mechanism of LDA-induced esophageal mucosal injury (EI) on underlying chronic acid reflux esophagitis (RE). AIM: The aim of this study was to clarify the effect of LDA on chronic RE in rats. METHODS: Esophagitis was induced in 8-week-old male Wistar rats by ligating the border between forestomach and glandular portion with a 2-0 silk tie and covering the duodenum with a small piece of 18-Fr Nélaton catheter. Seventy-eight chronic RE rat models were divided into five treatment groups, consisting of orally administered vehicle (controls), and aspirin doses of 2, 5, 50 or 100 mg/kg once daily for 28 days. EI was assessed by gross area of macroscopic mucosal injury, severity grade of esophagitis and microscopic depth of infiltration by inflammatory cells. RESULTS: Area of esophagitis in animals with aspirin dose of 100 mg/kg/day showed a 36.5% increase compared with controls, although it failed to achieve statistical significance (p = 0.812). Additionally, the rate of severe EI was increased in animals with aspirin dose of 100 mg/kg/day as compared with controls (p < 0.05). The grade of severity correlated with the depth of inflammation (r s = 0.492, p < 0.001). CONCLUSIONS: Maximal dose aspirin (100 mg/kg/day) contributed in exacerbating preexisting EI. LDA (2 and 5 mg/kg/day), on the other hand, did not affect chronic RE in this model. LDA seems to be safe for use in patients with chronic RE.

Effects of the body mass index (BMI) on the surgical outcomes of laparoscopic fundoplication for gastro-esophageal reflux disease: a propensity score-matched analysis.

PURPOSE: In the present study, we examined how the body mass index (BMI) affected the outcomes of laparoscopic fundoplication for GERD in patients, whose backgrounds were matched in a propensity score-matched analysis. METHODS: We divided the patients into two groups (BMI <25 kg/m2 and BMI ≥25 kg/m2). The following background information was matched for the propensity score-matched analysis: sex, age, degree of esophageal hiatal hernia, acid exposure time, and degree of reflux esophagitis. In total, 105 subjects were extracted in each group. The surgical outcomes and postoperative outcomes of patients with BMI <25 kg/m2 (Group A) and those with BMI ≥25 kg/m2 (Group B) were compared and examined. RESULTS: There were no differences in the surgical procedure, intraoperative complications, or estimated blood loss (p = 0.876, p = 0.516, p = 0.438, respectively); however, the operative time was significantly prolonged in Group B (p = 0.003). The rate of postoperative recurrence in Group A was 17% (15/87 patients), while that in Group B was 11% (12/91 patients), and did not differ to a statistically significant extent (p = 0.533). CONCLUSIONS: Although the operative time for GERD in obese patients was prolonged in comparison with non-obese patients, there was no difference in the rate of postoperative recurrence.